# A nurse is caring for a client with Ménière's syndrome who is experiencing an acute episode. Which nursing intervention should be the priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541711 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a client with Ménière's syndrome who is experiencing an acute episode. Which nursing intervention should be the priority? ## 보기 1. Encourage the client to ambulate to prevent complications of immobility 2. Place the client in a quiet, darkened room and maintain bed rest **✔ 정답** 3. Administer prescribed antihistamines and encourage fluid intake 4. Position the client in high Fowler's position to improve circulation **정답: 2** ## 해설 During an acute Ménière's episode, severe vertigo poses a high fall risk, making safety the priority. Placing the client in a quiet, dark room with bed rest minimizes stimuli and prevents falls. Other options are inappropriate: ambulation increases fall risk, antihistamines/fluids are not immediate priorities, and high Fowler's does not address vertigo. ## 심화 해설 Understanding the Priority During an Acute Ménière's Episode The correct answer is to place the client in a quiet, darkened room and maintain bed rest. The rationale for this intervention as the top priority is rooted in the pathophysiology of an acute Ménière's attack and the fundamental nursing principle of safety. During an acute episode, the client experiences severe vertigo, a form of unilateral peripheral vestibular dysfunction (UPVD), which is the hallmark symptom of Ménière's disease [3]. This is not a simple feeling of dizziness; it is an intense, often violent sensation of rotational movement that creates a profound loss of spatial orientation and postural stability. The primary nursing priority in this scenario is preventing physical injury from a fall. The sensory conflict between the abnormal signals from the affected inner ear and the input from the eyes and proprioceptors is what drives the vertigo. Any head movement, visual stimuli, or attempts to ambulate will exacerbate this conflict, intensifying the vertigo, nausea, and risk of falling. Analysis of the Priority Intervention The intervention of bed rest in a quiet, darkened room directly addresses the underlying pathophysiology by minimizing the sensory inputs that the brain must process. - Minimizing Vestibular Stimulation: Bed rest restricts head movement, thereby reducing the stimulation of the malfunctioning semicircular canals in the inner ear. - Reducing Visual Stimulation: A darkened room eliminates the visual input that contradicts the aberrant vestibular signals. In a lit room, the eyes tell the brain the environment is stable, while the inner ear signals violent motion. This sensory mismatch is what drives the vertigo. - Reducing Auditory Stimulation: Ménière's episodes are often accompanied by hyperacusis (sensitivity to sound) and worsening tinnitus. A quiet environment prevents auditory stimuli from adding to the overall sensory overload and distress. Why Other Options Are Not the Priority - Option 1 (Encourage ambulation): This is contraindicated and unsafe. During an acute vertigo attack, the client’s balance is severely compromised, making ambulation a high-risk activity for falls and injury. Vestibular rehabilitation exercises, which include balance training, are an effective management strategy for chronic, stable UPVD, but they are implemented after the acute episode has subsided, not during it [3]. - Option 3 (Administer prescribed antihistamines and encourage fluid intake): While administering a prescribed vestibular suppressant, such as an antihistamine (e.g., meclizine), is an important medical intervention to reduce the intensity of vertigo, it is not the nursing priority. Safety takes precedence. The nurse must first stabilize the client in a safe environment before leaving to obtain and administer medication. Furthermore, encouraging fluid intake during an acute episode can worsen severe nausea and vomiting, which are common associated symptoms. - Option 4 (High Fowler's position): This position is not therapeutic for vertigo and would be counterproductive. The goal is to keep the head as still as possible. A completely flat or position of comfort is preferred. High Fowler's position elevates the head, which could increase head movement and worsen the sensation of falling. The initial and most critical nursing action is to create a safe, low-stimulation environment by assisting the client to bed rest in a quiet, darkened room to immediately reduce the severity of the vertigo and prevent injury [1, 3].References (research sources) - [3]Vestibular rehabilitation for unilateral peripheral vestibular dysfunction.Research articleMcDonnell MN, Hillier SL. (2015) · DOI: 10.1002/14651858.cd005397.pub4 ## 임상 시나리오 Acute Vertigo Safety ProtocolImmediate nursing actions for a Ménière's attack The immediate priority is fall prevention. Instruct the client to lie down immediately and maintain strict bed rest in a quiet, darkened room. Minimize sensory stimulation: close the door, dim the lights, and reduce environmental noise. Keep the bed in its lowest position with side rails up per facility policy. Administer prescribed vestibular suppressants (e.g., meclizine or diazepam) and antiemetics as ordered. Avoid sudden head movements during care. CautionDo not encourage ambulation or active range of motion during the acute phase. The sensation of violent spinning causes postural instability and a high risk of injury. ## 핵심 개념 - **Ménière's Disease** — A disorder of the inner ear characterized by episodic vertigo, tinnitus, hearing loss, and a feeling of fullness in the ear. - **Vertigo** — A sensation of spinning or rotational movement, often severe in acute Ménière's attacks, caused by a conflict in sensory inputs to the brain. - **Unilateral Peripheral Vestibular Dysfunction (UPVD)** — A disturbance in the balance mechanism of one inner ear, leading to asymmetric signals and severe vertigo. ## 같은 주제 문제 - [A nurse is assessing a 52-year-old client who reports episodes of severe dizziness, hearin…](https://mymerci.kr/pages/nclex_q.php?qn_id=541707) - [A nurse is assessing a 38-year-old client who presents to the emergency department with co…](https://mymerci.kr/pages/nclex_q.php?qn_id=541708) - [A nurse is caring for a client with Ménière's syndrome who is experiencing an acute episod…](https://mymerci.kr/pages/nclex_q.php?qn_id=541709) - [A nurse is caring for a client with Ménière's syndrome who is experiencing an acute episod…](https://mymerci.kr/pages/nclex_q.php?qn_id=541710) - [A nurse is caring for a client with Ménière's syndrome who is experiencing an acute episod…](https://mymerci.kr/pages/nclex_q.php?qn_id=541712) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._